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Patient Survey - Dr Johnson 2015

1. Your Doctor's Care

As part of our ongoing efforts to improve, we'd like to find out how you feel about the care your doctor is providing. Your responses with be confidential and anonymous. Thanks for your time!

Question Title

* 1. Please mark how well your doctor:

	Poor	Fair	Okay	Good	Great	N/A
Shows that he/she cares for you.	Shows that he/she cares for you. Poor	Shows that he/she cares for you. Fair	Shows that he/she cares for you. Okay	Shows that he/she cares for you. Good	Shows that he/she cares for you. Great	Shows that he/she cares for you. N/A
Shows respect toward you as a person.	Shows respect toward you as a person. Poor	Shows respect toward you as a person. Fair	Shows respect toward you as a person. Okay	Shows respect toward you as a person. Good	Shows respect toward you as a person. Great	Shows respect toward you as a person. N/A
Respects your privacy.	Respects your privacy. Poor	Respects your privacy. Fair	Respects your privacy. Okay	Respects your privacy. Good	Respects your privacy. Great	Respects your privacy. N/A
Listens to you.	Listens to you. Poor	Listens to you. Fair	Listens to you. Okay	Listens to you. Good	Listens to you. Great	Listens to you. N/A
Communicates with you and your family.	Communicates with you and your family. Poor	Communicates with you and your family. Fair	Communicates with you and your family. Okay	Communicates with you and your family. Good	Communicates with you and your family. Great	Communicates with you and your family. N/A
Answers your questions.	Answers your questions. Poor	Answers your questions. Fair	Answers your questions. Okay	Answers your questions. Good	Answers your questions. Great	Answers your questions. N/A
Has a good working relationship with you.	Has a good working relationship with you. Poor	Has a good working relationship with you. Fair	Has a good working relationship with you. Okay	Has a good working relationship with you. Good	Has a good working relationship with you. Great	Has a good working relationship with you. N/A
Includes you in making decisions about your healthcare.	Includes you in making decisions about your healthcare. Poor	Includes you in making decisions about your healthcare. Fair	Includes you in making decisions about your healthcare. Okay	Includes you in making decisions about your healthcare. Good	Includes you in making decisions about your healthcare. Great	Includes you in making decisions about your healthcare. N/A
Gives you information you need to make decisions about your healthcare.	Gives you information you need to make decisions about your healthcare. Poor	Gives you information you need to make decisions about your healthcare. Fair	Gives you information you need to make decisions about your healthcare. Okay	Gives you information you need to make decisions about your healthcare. Good	Gives you information you need to make decisions about your healthcare. Great	Gives you information you need to make decisions about your healthcare. N/A
Respects your decisions.	Respects your decisions. Poor	Respects your decisions. Fair	Respects your decisions. Okay	Respects your decisions. Good	Respects your decisions. Great	Respects your decisions. N/A
Explains your diagnosis and treatment plan.	Explains your diagnosis and treatment plan. Poor	Explains your diagnosis and treatment plan. Fair	Explains your diagnosis and treatment plan. Okay	Explains your diagnosis and treatment plan. Good	Explains your diagnosis and treatment plan. Great	Explains your diagnosis and treatment plan. N/A
Is sensitive to any needs specific to your gender, age, culture, religion, disability, or sexual orientation.	Is sensitive to any needs specific to your gender, age, culture, religion, disability, or sexual orientation. Poor	Is sensitive to any needs specific to your gender, age, culture, religion, disability, or sexual orientation. Fair	Is sensitive to any needs specific to your gender, age, culture, religion, disability, or sexual orientation. Okay	Is sensitive to any needs specific to your gender, age, culture, religion, disability, or sexual orientation. Good	Is sensitive to any needs specific to your gender, age, culture, religion, disability, or sexual orientation. Great	Is sensitive to any needs specific to your gender, age, culture, religion, disability, or sexual orientation. N/A
Helps you get the care you need within the healthcare system.	Helps you get the care you need within the healthcare system. Poor	Helps you get the care you need within the healthcare system. Fair	Helps you get the care you need within the healthcare system. Okay	Helps you get the care you need within the healthcare system. Good	Helps you get the care you need within the healthcare system. Great	Helps you get the care you need within the healthcare system. N/A

Comments:

Question Title

* 2. Please rate your overall satisfaction with your doctor.

Poor

Good

Okay

Good

Great

Poor

Good

Okay

Good

Great